Dementia and Dysphagia Dr. David T. Hutchings, CCC SLP.D. Vice President of Therapy Services Amedisys, Inc Overview, 98 individuals turn daily 0 individuals turn per hour 0 million baby boomers will develop dementia Every seconds someone is dx with AD Midcentury every seconds someone will be dx with AD.8% have dementia in ALF % of the.8% have significant behavioral symptoms associated with the dementia % moderate to severe dementia MMSE and Function in the Home 0 Keeping appointments (ie., doctor etc..) Meal Preparation Walking/Ambulation Transfers Medication management Other High Level ADLs 0 Safety in the home Use of appliances in the home Dressing, grooming, selecting cloths to wear Toileting Communication Finding objects in the home Below Eating Swallowing Inappropriate behaviors Appetite Sensation Communicating Wants and Needs
Assessment Date Date Date Date Date Brief Cognitive Rating Scale (BCRS)* Barry Reisberg, M.D. Rating Rating Rating Rating Rating (Circle the Highest Rating Attained) Axis I: Concentration = No objective or subjective evidence of deficit in concentration. = Subjective decrement in concentration ability. = Minor objective signs of poor concentration (e.g., subtraction of serial 's from 00). = Definite concentration deficit for persons of their backgrounds (e.g. marked deficit on serial 's; frequent deficit in subtraction of serials 's from 0). = Marked concentration deficit (e.g., giving months backwards or serials 's from 0). = Forgets the concentration task. Frequently begins to count forward when asked to count backwards from 0 by 's. = Marked difficulty counting forward to 0 by 's. Axis II: Recent Memory = No objective or subjective evidence of deficit in recent memory. = Subjective impairment only (e.g., forgetting names more than formerly). = Deficit in recall of specific events evident upon detailed questioning. No deficit in recall of major recent events. = Cannot recall major events of previous weekend or week. Scanty knowledge (not detailed) of current events, favoritetv shows, etc. = Unsure of weather; may not know current President or current address. = Occasional knowledge of some events. Little or no idea of current address, weather, etc. No knowledge of any recent events. Axis III: Past Memory = No subjective or objective impairment in past memory. = Subjective impairment only. Can recall two or more primary school teachers. = Some gaps in past memory upon detailed questioning. Able to recall at least one childhood teacher and/or one childhood friend. = Clear cut deficit. The spouse recalls more of the patient's past than the patient. Cannot recall childhood friends and/or teachers but knows the names of most schools attended. Confuses chronology in reciting personal history. = Major past events sometimes not recalled (e.g., names of schools attended). = Some residual memory of past (e.g., may recall country of birth or former occupation). = No memory of past.
Axis IV: Orientation = No deficit in memory for time, place, identify of self or others. = Subjective impairment only. Knows time to nearest hour, location. = Any mistakes in time > hours: day of week > day; date > days. = Mistakes in month > 0 days or year > month. = Unsure of month and/or year and/or season; unsure of locale. = No idea of date. Identifies spouse but may not recall name. Knows own name. = Cannot identify spouse. May be unsure of personal identity. Axis V: Functioning and Self Care = No difficulty, either subjectively or objectively. = Complains of forgetting location of objects. Subjective work difficulties. = Decreased job functioning evident to coworkers. Difficulty traveling to new locations. = Decreased ability to perform complex tasks (e.g., planning dinner for guests, handling finances, marketing, etc.) = Requires assistance in choosing proper clothing. = Requires assistance in feeding, and/or toileting, and/or bathing, and/or ambulating. = Requires constant assistance in all activities of daily life. =Total Score /= /= /= /= /= Stage on Global Deterioration Scale (GDS)
Normal Swallowing
What is Dysphagia? Dysphagia is an impairment in the swallowing function that may occur anywhere from the mouth to the stomach (Perlaman, 99). Dysphagia Causes Pneumonia Prevalence of Dysphagia Mainly associated with advanced aging The incidence is approximately % in the geriatric population and is associated with significant morbidity and mortality Noted to result in weight loss, poor nutrition, dehydration, decubitus, social isolation, aspiration pneumonia and even death Approximately 8% of the SLPs caseload in home heath are dysphagia patients Over the past decade, the number of hospitalized elderly Medicare beneficiaries admitted to the hospital with a dx of aspiration pneumonia has increased 9.8%. Overview of Normal Swallow 00 swallows/day avg. stages: Oral Preparation Requires lip closure Jaw elevation, depression and rotary movements Anterior tongue control Posterior tongue elevation to close off airway from oral Oral Transit Sending the bolus from the anterior to posterior Pharyngeal Involuntary neurological event that elevates the larynx and closes off the airway.
Oral Prep and Oral Phase Normal Oral Prep and Oral Phases: Food preparation Hand to mouth Food is bitten off or taken from a utensil Liquids are sipped via cup or sucked through a straw Oral manipulation/mastication Bolus formation Bolus propulsion Oral Transit Pharyngeal Phase Normal Pharyngeal Phase: Soft Palate elevates Tongue base makes contact with pharyngeal wall Hyolaryngeal excursion initiates Breathing momentarily stops Airway closes Vocal cords close Epiglottis inverts Muscles of the pharynx contract Upper esophageal sphincter (UES) opens 9//0
Normal Laryngeal Dysphagia Normal Laryngeal Elevation: Normal laryngeal elevation should be approximately cm in men and. cm in women, with some reduction of to mm over the age of 80. (Logemann: Medical and rehabilitative therapy of oral, pharyngeal motor disorders) Airway Protection (Corbin Lewis, Liss, J.M. & Sciortino, K.L) Pharyngeal Phase consists of several events for airway closure:. Velopharyngeal Closure. Inversion of the epiglottis over the laryngeal entryway. Anterior and superior hyoid displacement. Closure of the true and false vocal folds. Progressive pharyngeal contraction. Opening of the UES Geriatric Swallowing Evaluation Summary Age changes to swallow Diagnoses Cranial Nerve Assessment Oral care issues (How can Diagnoses impact swallow and at what stage(s)) PEG Tube Rate, positioning, family support, oral care, Personal history length of PEG placement, etc. MBS Environment Cognition Medication Review Oral Weight Loss, malnutrition, dehydration Pharyngeal Respiration (SOB) Aspiration Change in Temperature Before/During or After the Swallow Structural Assessment Symptoms of aspiration (Patient doesn t have May want to recommend MBS for CA patients to aspirate during evaluation for us to treat.) 8
Dementia and Dysphagia Think Beyond Aspiration Aspiration Choking Tracheostomy Malnutrition Dehydration Weight loss Wound Pressure Ulcer Chronic Respiratory Illness PEG or J Tube Confusion Death 9
Aspiration in Dementia *** Aspiration is only one symptom of dysphagia 0% of aspiration is silent aspiration 8% of CVA pts have silent aspiration Common Signs and Symptoms of Aspiration: Coughing during or after eating Feeling of food sticking in throat Runny Nose Watery Eyes Gurgled Vocal Quality Loss of Weight Dehydration Temperature increases associated with meals and intake Dementia and Dysphagia People with cognitive impairment develop Dysphagia Dementia residents exhibit: Changes in behavior during meals Sensory loss affecting ability to eat, swallow, follow treatment strategies Motor loss affecting ability to initiate swallow Primary cause of dysphagia in dementia = intellectual impairment Dysphagia and Dementia Sensory damage can disrupt the process of bolus organization, mastication and Oral Transit. Motor damage caused by dementia can disrupt airway closure and pharyngeal movement. Due to Sensory and Motor Damage dementia patients demonstration aspiration, silent aspiration, bronchiectasis, dehydration, weight loss, and starvation 0 0
Sensory Considerations The degree to which sensory information activates motor response remains uncertain SLPs are encouraged to probe the effects of heightened sensory input with strong smell and taste (as well as texture and temperature) information to increase the opportunity for persons with dementia to recognize, interpret and react to the bolus 000s of Sensory Receptors in the anterior oral mucosa Chemoreceptors (taste, smell, pain) Mechanoreceptors (touch, kinesthesia) Thermoreceptors (temperature, pain). Early Stage Dementia: Effects on swallowing, nutrition and hydration Tristani (0) Mild Cognitive Impairment Depression Taste and smell dysfunction Awareness of cognitive deficits Attention Mildly impaired Distracted intermittently throughout the meal Medications and polypharmacy Decreased nutrition and hydration due to MCI and depression Middle Stage Dementia: Effects on swallowing, nutrition and hydration Tristani (0) Wandering Motor restlessness Assistance needed for adequate oral care Cognitive based dysphagia Attention Moderately impaired Distracted periodically throughout the meal Texture aversion Medications and polypharmacy Is it possible to forget to eat??
Advanced/Late/End Stage Dementia: Effects on swallowing, nutrition and hydration Tristani (0) Cognitive Based Dysphagia Dependence on oral care Oral apraxia Oral acceptance deficits Oral preparatory deficits Attention Mod severely impaired often distracted Texture aversion Medications and polypharmacy Pharyngeal phase deficits and aspiration Advanced/Late/End Stage Dementia: Effects on swallowing, nutrition and hydration Tristani (0) Over chewing Severe myoclonus Twitching in oral musculature Self feeding ability is lost Individuals become dependent on others for meal consumption Summary of Dysphagia and AD Dysphagia in early stage AD: Delayed pharyngeal swallow; reduced lingual movement Dysphagia in mid stage AD: Reduced oral prep., pharyngeal clearance, UES opening, (+) asp Dysphagia in late stage AD: Increased aspiration pneumonia, leading to death
Oral Prep and Oral Phase Deficits in Oral Prep and Oral Phase: Prolonged chewing and pocketing Open mouth posture Oral Residue post swallow Increased food prep time Excessive manipulation time Lingual pumping Difficulty forming the bolus Difficulty throwing the bolus Oral residue post swallow Pharyngeal Phase Deficits: Pharyngeal Phase Pharyngeal delay difficulty triggering the swallow Laryngeal penetration: Material enters the top of the airway but does not drop below the vocal cords. Aspiration Silent Aspiration Pharyngeal residue: Material remains in the throat post swallow 8 Dysphagia Management For Dementia Patients
Current Treatment for Dysphagia Compensation interventions Feeding Tubes Diet modifications Oral Care Feeding Techniques Positioning 0 Feeding Tube Myths Prevent Malnutrition Maintain Skin Integrity Prevent Aspiration Pneumonia Improve Quality of Life Func onal Status and Survival No improvement of nutritional markers risk for pressure ulcer forma on Never shown to aspira on pneumonia incidence May suffering and discomfort Never shown to life span FA Cervo., L Bryan.,& S Farber PEG Tubes 8% SLPs Believe Improve Nutritional Status in Advanced Dementia Risk of Aspiration Pneumonia Outcomes data does not support this belief that PEG tube feeding reduces the risk of aspiration pneumonia (Finucaneet al., 999).
Diet Modifications: National Dysphagia Diet (NDD): Russell (00). Diet Level NDD Level : Dysphagia Pureed NDD Level : Dysphagia Mechanically Altered NDD Level : Dysphagia Advanced NDD Level : Regular Description All foods must be pureed and thickened (if necessary) to a pudding like consistency. It must be lump free or no chewing is required All foods are moist, soft textured and easily chewed. Meats are ground and served with gravy or sauce. Cooked breakfast cereals and soft pancakes moistened with syrup are included. Tuna Salad and egg are allowed. Some chewing is required. Includes most regular consistency foods but excludes hard, dry, sticky, or crunch foods. Food should be moist and in bite size pieces. Dry breakfast cereals must be well moistened and meats must be tender. Lettuce can be served if shredded. No restrictions National Dysphagia Diet (NDD) Textures Thin: Honey like: Spoon/Pudding like: Nectar like: Oral Care Conduct after each meal Make it a focus of your treatment Make it a goal Quality of Life Diet compliance from patient
Common Difficulties with Eating and Drinking Reduced Interest in food and drink Appetite Forget to eat and drink Increase in meal time requirement Cough and choke with intake Refuse food Weight loss Dysphagia Impaired sense of smell Feeding Devices in Dementia o o o o o o o Provale Cup Maroon Spoon Use with feeding problems such as poor lip closure, tongue, throat and oral hypersensitivity Soft Spoon Use with patients who bite down Flexi Cut Cup Can be squeezed gently to change the shape of the cup lid. Nosey cup section plate Infant spoons Optimal Task Presentation Early Stage Dementia inches Middle Stage Dementia inches With visual perceptual deficits Late Stage Dementia inches from the midline Significantly diminished visual perceptual processing
The Feeding Experience General Feeding Tips Make sure patient is ready to eat Provide quiet, inviting environment Promote calm Sit at eye level Use boundaries Take time No garnishes Serve promptly Offer liquids throughout day Assure dignity 9 Tips for Encouraging Intake Ensure proper temperature of foods Use finger foods Small portions More intake in morning Add sweetener Ethnic/culturally appropriate foods Alternate food choices Tell patient meal is paid for 0 Feeding Devices in Dementia Treatment Techniques The coated spoon Cold, metal spoon presentation Adaptive equipment Patient routine adaptations timing of meals capitalize on patient routine at PLOF Alternate hot cold Diet texture modification
Treatment Techniques Timing, readiness, latency techniques Use of distraction Tactile, visual, verbal cues & modeling Behavioral strategies Finger foods When it is difficult to use a utensil When it is helpful to ambulate and eat When in doubt COMBINE Treatment Techniques Visual cues and written reminders Limit the number of utensils Use one step directives for cueing and encouraging PO Dining area should be in a home like environment dining room etc. Serve larger portions at breakfast to maintain weight Offer liquids and water consistently throughout the day Patients can be tempted to eat more with sweetener added Treatment Techniques Increase number of finger foods Alternate hot, cold, sweetener, and alternate with spicy foods, add ketchup, mustard, salt, pepper (if medically appropriate) Tell concerned patients their meal is paid for and included in a meal club Do not use garnishes or decorations or meal tray slips, as they are easy picked up and eaten. Use boundaries by using place mats or square tables to reduced interest in another persons meal 8
Compensation Techniques for Dysphagia Appropriate Positioning Chin Tuck Head Rotation Rotation and Chin Tuck External Pressure to the Cheek Labial and Chin Support Multiple Swallows Supportive Feeding in Dementia General Feeding Techniques Try chin tuck (may need to support head in this position with rolled towels) Use a small spoon to avoid putting too much food in the mouth at once Watch/feel for the swallow; do not give more food or drink until they have swallowed Remind the person to chew each mouthful thoroughly Touch the person's lower lip to stimulate opening the mouth Massage the throat to stimulate the swallow reflex Use one step directives for cueing and encouraging PO Oral care after each meal Ensure the person remains sitting in an upright position for at least 0 minutes after each meal Feeding Techniques: Concentration Deficits Feeding Techniques Plan any exercise for about hour before mealtime Verbalize each step of the eating process Physically place utensils in hand Play the same soft music at every meal, sit in the same chair at every meal, etc. Clear room of distractions, when possible Make sure that food and utensils are visible Move yourself to maintain eye contact with the person, while stating that it is now mealtime Describe each food item to the person (i.e., Here we have some green Jell O ) 9//0 9
Feeding Techniques: Combative/Throws Food Feeding Techniques Schedule aerobic activity prior to mealtime Remove the item that was thrown Consider using suction cups to affix dishes to table Stand or sit on non dominant side Provide only one food at a time Reward good mealtime behavior Provide a calm environment for mealtime Do not show any response to the person s combative behavior remain calm Tell the person that you need him/her to stop behaving in this way Re approach at a later time 8 Feeding Techniques: Chews Constantly Feeding Techniques Empty Spoon Technique Provide soft foods that require less chewing Offer small bites Touch the individual s jaw as a reminder that the he/she is making chewing motions Some people can follow verbal cues, such as still, in between bites of food (i.e., Chew. Still. Open up. Chew. Still. ) 9//0 9 Feeding Techniques: Eats Quickly Feeding Techniques Encourage the person to set utensils down between bites Offer food items one at a time Offer foods that require more chewing Use small utensils Divide foods in half, offer one half at a time, and ask if the person would like some more food before providing it Attempt to engage the person in conversation between bites to make them more aware of the meal: Describe each food item to the person or ask them to describe it to you Try to assess degree of hunger and serve between meal snacks, if necessary 0 0
Feeding Techniques: Eats Slowly Feeding Techniques Provide verbal cues (i.e., Take a bite. Chew. Swallow. ) Use insulated dishes to maintain appropriate temperature Remind the person of what is planned after the meal Remove any distractions from the room Do not allow the person to become overwhelmed by providing too much variety at one meal or by providing too large of portions Make sure that meals are appropriately spaced and are not served too close together Feeding Techniques: Forgets to Swallow Feeding Techniques Verbally remind the person to swallow Feel for swallow after each bite Stroke larynx upward Try using prompts some people can learn prompts to remind them to swallow, such as a hand squeeze or a light tap on the arm 9//0 Feeding Techniques: Poor Attention and Plays with Food Feeding Techniques Provide finger foods Cover dishes and only uncover one at a time Only serve one food at a time Watch for patterns in behavior (does the person play with food more when tired, overwhelmed, etc.) and modify daily routine, as necessary Gently pull the person s hand away from the meal and clearly say no Wipe the person s hands off every time that food is touched, rather than using utensils Verbally remind the person that this is mealtime and that it is time to eat
Feeding Techniques: Patients with Paranoia Feeding Techniques Provide a consistent routine Do not mix medicines into food Explain what each food item is Prepare foods in front of the person (sometimes necessary) or allow them to assist in preparation, if possible Do not serve new food items; try to stick to the familiar Keep foods as simple as possible, avoiding complicated casseroles, etc. Care Delivery Model for Dementia: Multidisciplinary Physician Medical Social Worker Physical Therapy Skilled Nursing Occupational Therapy Speech Language Pathology